Epidemiologic Notes and Reports Spectinomycin-Resistant Neisseria gonorrhoeae -- Worldwide

Until recently, only eight isolates of spectinomycin-resistant Neisseria gonorrhoeae had been reported worldwide; four were penicillinase-producing N. gonorrhoeae (PPNG), and four were non-PPNG (1). During the last 4 months, however, six additional isolates of spectinomycin-resistant gonococci have been identified and reported. Available details on these cases highlight the potential magnitude of the problem.

Non-PPNG case: A 21-year-old U.S. airman stationed at Osan Air Force Base, Republic of Korea, was seen at the Osan hospital clinic July 20, 1982, with a 3-day history of purulent urethral discharge that began 3 days after sexual exposure to a prostitute. A Gram stain was consistent with gonorrhea, and he was treated with spectinomycin 2 g intramuscularly (IM). Cultures of the discharge grew beta-lactamase-negative N. gonorrhoeae susceptible to penicillin and spectinomycin.

On July 27, the patient returned for a scheduled test of cure. He remained symptomatic with purulent urethral discharge on examination, and the gram-stain smear was again consistent with gonorrhea. He was given 4 g of spectinomycin IM. Cultures of the urethral exudate grew beta-lactamase negative N. gonorrhoeae susceptible to penicillin but resistant to spectinomycin.

Symptoms persisted until July 30, when the patient was hospitalized for further evaluation and definitive therapy. A gram-stain smear was still consistent with gonorrhea. Urethral cultures were positive for N. gonorrhoeae susceptible to penicillin but resistant to spectinomycin. He was given 4.8 million units of procaine penicillin IM and 1 g of probenecid orally. His symptoms resolved, and cultures of post-treatment urethral specimens were negative.

PPNG cases: Since a September 17 report (1), five additional cases of infection with PPNG resistant to spectinomycin have been reported. A spectinomycin-resistant PPNG isolate was obtained in Detroit from a 25-year-old male whose last sexual exposure was to a 30-year-old female in London between July 23 and August 7, 1982. A pretreatment isolate on September 8 was beta-lactamase negative and susceptible to penicillin and spectinomycin. Treatment with tetracycline, followed by ampicillin and probenecid, did not cure the infection. Subsequent urethral cultures grew beta-lactamase-positive, spectinomycin-resistant N. gonorrhoeae. The patient was successfully treated with cefotaxime 1 g IM.

Two cases were reported from London in males aged 30 years and 23 years (2); Asian-type plasmids were found in both. Two other cases have recently been reported to the Venereal Disease Reference Laboratory in London (3). Reported by AJ Patefield, MD, USAF Hospital, Osan, Korea; WG Westbrook III, MD, USAF Hospital, Yokata, Japan; NA Johnston, Venereal Diseases

Editorial Note

Editorial Note: Although still uncommon, seven apparently unrelated spectinomycin-resistant gonococcal infections have been identified since summer of 1982. Fourteen cases of spectinomycin-resistant gonorrhea (nine PPNG and five non-PPNG) have been noted worldwide since the first report in 1973 (4). Although the increase may reflect only improved surveillance, there is no evidence that surveillance has recently changed in London, where most of the cases have occurred.

The emergence of spectinomycin resistance could be the result of selection associated with increased use of spectinomycin worldwide. However, induction of resistance is another possibility. Pre-treatment isolates were susceptible to spectinomycin, but post-treatment isolates were resistant, emphasizing that resistance may emerge in a single treatment period.

Health care personnel should be aware that not all patients treated with spectinomycin will be cured of gonorrhea. Post-treatment cultures should be an integral part of patient management. All PPNG isolates and isolates from patients with positive cultures after spectinomycin therapy should be tested for spectinomycin susceptibility using a provisional disc-diffusion method (4). Patients should be treated with cefoxitin 2 g IM in a single injection plus probenecid 1 g orally, or cefotaxime 1 g IM in a single injection (5).

Reference Laboratory, London; Sexually Transmitted Diseases Laboratory

1. CDC. Spectinomycin-resistant B-lactamase-producing Neisseria gonorrhoeae--England. MMWR 1982;31:495-6, 501.

2. Spectinomycin-resistant B-lactamase-producing Neisseria gonorrhoeae. Communicable Disease Report (London) Sept. 17, 1982.

3. Veneral Disease Reference Laboratory. Unpublished data.

4. Reyn A, Schmidt H, Trier M, Bentzon MW. Spectinomycin hydrochloride (Trobicin) in the treatment of gonorrhoea. Observation of resistant strains of Neisseria gonorrhoeae. Br J Vener Dis 1973;49:54-9.

5. CDC. Sexually transmitted diseases, treatment guidelines 1982. MMWR 1982;31 (supplement 2S):35S-60S.

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